Effects of the Affordable Care Act Among Cancer Survivors: Expanded Insurance Options and Other Impacts The webinar will begin at 1:00 p.m. Eastern. Audio: Use computer speakers or phone (1-866-307- 6424) If connecting by phone, please put your phone on mute!
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Effects of the Affordable Care Act Among Cancer Survivors:
Expanded Insurance Options and Other Impacts
The webinar will begin at 1:00 p.m. Eastern. Audio: Use computer speakers or phone (1-866-307-
6424) If connecting by phone, please put your phone on mute!
Agenda Topic Presenter
Welcome and Overview of the GW Cancer Institute
Mandi Pratt-Chapman, MA GW Cancer Institute
Effects of the Affordable Care Act Among Cancer Survivors: Expanded Insurance Options and Other Impacts
Amy J. Davidoff, PhD Yale School of Public Health
Question & Answer
All
GW Cancer Institute
• Founded in 2003
• Vision: To set the standard for patient-centered care and eliminate cancer health disparities.
• Mission: To ensure access to quality, patient-centered care across the cancer continuum through community engagement, patient and family empowerment, health care professional education, policy advocacy, and collaborative multi-disciplinary research.
GW Cancer Institute TA Project Online Academy
Comprehensive resource guides
Connecting CCC practitioners with experts
Supporting integration of cancer prevention with other chronic disease prevention efforts
Large-group, small-group, and one-on-one technical assistance for CCC grantees and coalitions
Creating easier ways to align local initiatives with national health priority indicators
• Small business Health Options Program (SHOP) exchanges
• Employer mandate
• Non-compliant non-group plans permitted
– 23 states not planning to expand Medicaid
– Individuals losing “grandfathered” plans; facing higher costs to purchase new plans
• The ugly: politics, politics, politics
Focus for Today’s Webinar
• Cancer survivor experience with insurance, access, cost-sharing pre-ACA
• Review of selected elements of ACA as of 2014
• Drill down – expected effects of the ACA for cancer survivors
Where did cancer survivors get coverage before the ACA?
11 7
15 25
68 63
4 1 3 3
0%
20%
40%
60%
80%
100%
Cancer Survivors No Cancer History
Employment related/TriCare
Medicare
Other
Source: Medical Expenditure Panel Survey, 2008-2010 Point in time insurance estimates for non-elderly adults, Davidoff et al., unpublished.
Medicaid
Uninsured
Despite lower uninsured rates, cancer survivors faced barriers to insurance pre-
ACA
Cancer history may limit offers of ESI • Most large firms offer ESI to FT workers
• Employment related coverage limited for PT workers, short tenure, even in large firms
• Cancer history may limit employment => reduced ESI offers
• Smaller firms may be subject to underwriting (depending on state regs) – High cost/high risk employee or dependent may
=> prohibitive premiums for group Sources:
Farber HS1, Levy H. J Health Econ. 2000 Jan;19(1):93-119. Mehnert A. Crit Rev Oncol Hematol. 2011 Feb;77(2):109-30. Davidoff A, Blumberg L, Nichols L. J Health Econ 24:725-50, 2005
Cancer history may have precluded insurance purchase in non-group market
• Non-group = individual = private purchase market • Absent specific state regulation, insurers engage
in underwriting to assess risk – Deny coverage if cancer history – Exclude coverage of cancer-related services – Charge exorbitant premiums
• State regulations impact of some insurer practices – Guaranteed issue – Risk rating restrictions
Source: Pollitz K, Sorian R: Ensuring health security: is the individual market ready for prime time? Health Aff (Millwood) Suppl Web Exclusives:W372-6, 2002
Even Medicare enrolled cancer survivors may experience barriers to supplemental insurance
• Medicare beneficiaries account for 2/3 of new cancer diagnoses
• 90% receive Medicaid, are enrolled in retiree health insurance, or purchase Medigap
• Supplemental coverage access limited if cancer diagnosis preceded Medicare enrollment
• Medigap enrollment subject to underwriting if permitted by state regulations
Medicaid & SCHIP not a “safety net” for most cancer survivors
• Federal-state funded programs limited to categorically eligible – Children, pregnant women, parents of dependent
children – Very low income thresholds
• 35 states with medically needy programs permit “spend down”
• Some states expanded coverage to parents with higher incomes
• Few states covered non-elderly adults w/o dependent children
Large proportion of non-elderly cancer survivors faced high OOP burden
13.4 9.0
43.0
24.4 25.8
0.0
10.0
20.0
30.0
40.0
50.0
Overall Private group Non-group Public Uninsured
High OOP burden defined as OOP expenditure on healthcare and premiums > 20% family income.
Source: Bernard DS, Farr SL, Fang Z. National estimates of out-of-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008. J Clin Oncol. 2011 Jul 10;29(20):2821-6.
Many cancer survivors reported access barriers, although routine care rates
higher
19
85
46
95
80
65
13
70
30
85
60 61
0
20
40
60
80
100
Delay/Unmetneed
USOC Influenzavaccine
BP checked Cholesterollevel
Dental visit
Cancer Survivor No cancer historySource: Yabroff KR, Short PF, Machlin S, Dowling E, Rozjabek H, Li C, McNeel T, Ekwueme DU, Virgo KS. Access to preventive health care for cancer survivors. Am J Prev Med. 2013 Sep;45(3):304-12.
Key Elements of the ACA (but not every detail)
Individual Insurance Mandate
• All U.S. citizens and legal residents must have qualified insurance plan by 2014
• Failure to have coverage => tax penalty – Greater of $695 per year (up to three times that amount per
family) or 2.5% of household income. – Phased in over time
• Exemptions granted for financial hardship, religious objections, undocumented immigrants, prisoners
To facilitate individual mandate, ACA improves coverage access
• Eliminates health status as barrier to coverage
• Employer mandate • Marketplaces: New
source of private coverage – Premium subsidies for
lower income
• Public coverage expansions
Large employers mandated to offer coverage
• Employers with 50+ FT employees must offer qualified plan
• Penalty for employers that do not offer coverage and have 1+ FT employee who receives a premium tax credit
• SHOP exchanges, with tax credits for employers with < 25 employees
Buying Insurance in the New “Marketplace” • Centralized market for purchase of private insurance
plans • Plans
– Cover essential health benefits – 4 standard plans defined by actuarial value
• Bronze (60%) – platinum (90%)
• Varied deductibles, high deductible plans common
• OOP caps
• No lifetime, annual coverage limits
• Premiums vary by policy type (single, family), region, age, tobacco use
• 85% receiving premium tax credits, with or w/o additional OOP protections
Source: ASPE issue brief, “Health Insurance Marketplace: Summary Enrollment report for the initial annual open enrollment period.” May 1, 2014. http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014apr_enrollment.pdf
Medicaid Expansions for Non-Elderly Adults
The ACA also attempts to fix many coverage & delivery system
problems
• Mandated coverage of essential health benefits – Coverage of routine care for clinical trial participants
• Cost sharing caps, subsidies • Closing the Medicare Part D coverage gap • Focus on quality & value of care delivery • Support for essential workforce development • Support for research on healthcare delivery
Coverage of state-defined essential health benefits may reduce barriers to specific
services
• Based on benefits offered by large employer plans offered in state, supplemented as needed
• Must be covered by new plans issued for small employers, marketplace & non-group market plans, Medicare, Medicaid
• Grandfathered plans (issued before ACA) must notify enrollees of services not covered
Essential Health Benefits Ambulatory services, home health & hospice
Rehabilitative & habilitative services
Emergency services
Laboratory services
Hospitalization
Preventive and wellness care,
Mental health and substance use disorder services
Chronic disease management
Prescription drugs
Pediatric dental & vision care
Medicaid Benefits
• State-defined essential health benefits • Cost sharing limited for individuals <
100% FPG – E.g., $4 copay for outpatient services – Aggregate cap on premiums and cost-
sharing= 5% of income • Premiums permitted only for income
>150% FPL
Drill Down – (Expected) Effects of the ACA for Cancer Survivors
Simulating Adult Eligibility for Pre- & Post-ACA Insurance Options
• Data on non-elderly adult cancer survivors from Medical Expenditure Panel Survey, 2008-2010
Link federal & state rules – Medicaid & Marketplace subsidies • Age • Family structure • Income measurement
• Family units • Disregards* • Thresholds
• Restrictions on alternative coverage
Construct measures from MEPS Data • Age • Family structure • Income • ESI Offers • Current coverage
Eligibility indicators • Medicaid • Not eligible • Marketplace
premium subsidies • Alternative
affordable coverage • Marketplace w/o
subsidies (income > 400% FPG)
Cancer Survivor Eligibility Under the ACA
19% 4% 10%
24%
43%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
All
Not eligible
Marketplace subsidy
Alternative Affordable Coverage
Income > 400% FPG Non-Elderly Adults
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff et al., unpublished, under review.
Medicaid
Eligibility Under the ACA for Uninsured Cancer Survivors
28%
12%
31%
11% 16%
0%
10%
20%
30%
40%
50%
All States
Medicaid
Marketplace premium subsidies
Affordable alternative coverage
Income > 400% FPG
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff A, Hill S, Bernard D, Yabroff R, unpublished, under review.
Not eligible
Eligibility under the ACA for uninsured cancer survivors varies dramatically by
expansion status
48%
10%
0%
22%
22% 40%
12% 11%
16% 16%
0%
20%
40%
60%
80%
100%
Expansion States Non-Expansion States
Medicaid Not eligibleMarketplace premium subsidies Affordable Alternative CoverageIncome >= 400% FPG
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff A, Hill S, Bernard D, Yabroff R, unpublished, under review.
Expected Coverage Effects for Cancer Survivors
• Dramatically reduced proportion of cancer survivors uninsured – Residual group of survivors w/o coverage in states not
expanding Medicaid • Medicaid to cover larger share of adults with cancer • Shifting sources of private insurance • Medicare, Medicaid to seek alternative patient-
centered delivery systems – Medical home – Accountable Care Organizations
• Challenge: translate coverage into access
Will mandated coverage of essential health benefits have a big impact?
• Most large employer groups already covered these services
• Impact huge for those with non-group, or previously uninsured
• How likely is a big impact? – Many plans already provided screening w/o cost sharing – Copay may still be required if other services provided during
visit
• Lack of insurance not only barrier to screening – Lack of knowledge, not recommended by physician – Discomfort – Fear
• Challenge – education, outreach to overcome other barriers Source: McMorrow S, Kenney GM, Goin D. Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act. Am J Public Health. 2014 Jan 16. [Epub ahead of print]
ACA mandates coverage of routine care for clinical trials
• Goal = reduced financial barriers to clinical trial participation
• How likely is the impact? – Very low rates of clinical trial participation (<5%) – 18 states already had similar mandates
– Financial barriers play relatively small role in limiting participation
• Challenge – how to improve recruitment rates to take advantage of insurance coverage
Source: Kircher SM, Benson AB 3rd, Farber M, Nimeiri HS. Effect of the accountable care act of 2010 on clinical trial insurance coverage. J Clin Oncol. 2012 Feb 10;30(5):548-53.
Reduced cost sharing may protect survivors from financial “toxicity” of cancer
treatments • By 2014, lifetime & annual $ coverage limits
eliminated
• Cost sharing capped, but can still be substantial. – Bronze plan: $5,950 for individuals and
$11,900 for families in 2010 – Means-tested reductions in OOP spending
caps – E.g., 100-200% FPL: $1,983/individual and
$3,967/family
Closing the Part D coverage gap will smooth spending
• Part D coverage gap may discourage initiation, encourage discontinuation of oral chemotherapy, supportive care medications
• What is the likely impact? – Reduces cost shock associated with coverage gap – More common oral chemotherapies less
expensive => closing gap may facilitate continuity of drug use
– High $$$ copayment or coinsurance for newer oral chemotherapy agents will continue to be deterrent
Downstream availability of biosimilars likely to impact cost of cancer therapy
• ACA authorized FDA to approve generic biologic agents
• European Union experience suggests development of both: – “me too” biologics, slightly less expensive – truly interchangeable biosimilars much less
expensive • Ultimately U.S. implementation regulatory
process for biosimilars =>reduced cost sharing to individuals with cancer Source: Megerlin F, Lopert R, Taymor K, Trouvin JH. Health Aff 2013 Oct;32(10):1803-10.
The ACA initiated selected value-focused reimbursement changes
• Penalties to hospitals for readmissions, hospital acquired conditions, e.g. infections, common in cancer patients
• CMMI project to develop & simulate strategies to reimburse providers for outpatient oncology care – Oncology specific Accountable Care